DENTISTRY Burton A. Horwitz, DDS, MSD Patient Information Patient Registration & Health History Patient Name (Last, First, MI): Todayʼs Date: Birthdate: Age: Male ____ Female ____ Nickname: Childʼs Home Phone: Childʼs Home Address: School: Grade: Email Address We May Use: Tell Us About Your Child: Family Information Name of Person Who is Accompanying Your Child Today: Relationship: Do you have legal custody of this child? Yes ___ No ___ Is your child adopted? Yes ___ No ___ Parentʼs Marital Status: Single ___ Married ___ Separated ___ Divorced ___ Widowed ___ List brothers / sisters with ages: Motherʼs Information Name: Birthdate: Check Appropriate: Step-Mother Guardian Home Phone: Cell Phone: Work Phone: Employer: SSN: Fatherʼs Information Name: Birthdate: Check Appropriate: Step-Father Guardian Home Phone: Cell Phone: Work Phone: Employer: SSN: Responsible Party & Primary Dental Insurance Person Responsible for Account: Insurance Co. Name: Insurance Co. Address: Insurance Co Phone: Policy Ownerʼs Name: Policy Owners Birthdate: Relationship to Patient: Group Number: Policy Holder ID: Policy Ownerʼs Employer: Employerʼs Address: Secondary Dental Insurance Orthodontic Coverage: Yes No Insurance Co. Name: Insurance Co. Address: Insurance Co Phone: Policy Ownerʼs Name: Policy Owners Birthdate: Relationship to Patient: Group Number: Policy Holder ID: Policy Ownerʼs Employer: Employerʼs Address: Whom May We Thank For Referring You? General Dentist ❑ Friend/One of Our Patients ❑ Internet ❑ Other ❑ Shraddha Patel Kolappa, DDS Patient Registration & Health History
Transcript
PEDIATRIC DENTISTRYClayton Pediatric Dental Center
Whom May We Thank For Referring You?General Dentist ❑ Friend/One of Our Patients ❑ ! ! ! ! Internet ❑ Other ❑ ! !
Shraddha Patel Kolappa, DDSPatient Registration & Health History
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Medications: Medications:
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Medications:
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Health HistoryIs this your childʼs Þrst dental visit? Yes No Last Visit Date: ! ! Your General Dentist: ! ! ! Has your child had an unfavorable experience in a dental ofÞce? Yes No What are the main concerns for this dental visit? ! ! ! ! ! ! ! ! ! Have there been any injuries to the face, mouth teeth or chin? ! ! ! ! ! ! Have you been informed that your child has any missing or extra permanent teeth? ................................................Yes No Has your child had any pain / tenderness in his / her jaw joint (TMJ / TMD)? ............................................................Yes No Does your child brush his / her teeth daily? ...........Yes No Floss his / her teeth daily? .............................Yes No Is your home water supply city water or well water? Please check one: Well Water ! ! City Water ! If your child has ever experienced any of the following place a check mark in the box next to the item: ☑❑ Clenching / Grinding Teeth! ! ❑ Nail Biting ! ! ! ❑ Thumb/Finger/PaciÞer Sucking❑ Lip Sucking/Biting! ! ! ❑ Nursing Bottle Habits!! ❑ Tongue Thrust❑ Mouth Breather! ! ! ❑ Speech Problems
COMMENTS: ! ! ! ! ! ! ! ! ! !
Please describe your childʼs current physical health (circle one): Good! ! Fair! ! Poor Is your child currently under the care of a physician? ..................................................................................................Yes No Childʼs Physician: ! ! ! ! Phone Number: ! ! ! Date of last visit: ! !Please list all drugs / things your child is allergic to or write ÒNoneÓ: ! ! ! ! ! ! ! Is your child allergic to:! Latex.....Yes No !! Metals/Nickel..... Yes No Plastics.....Yes No Has your child had an unfavorable reaction to Penicillin, Aspirin, Novocaine or any other medication?Please discuss any ÒYesÓ answers to the above: !! ! ! ! ! ! ! ! !
Has your child ever had any of the following medical problems? Circle Y for Yes and N for No
Y N Abnormal Bleeding! ! ! Y N ! Asthma!! ! ! Y N ! Heart MurmurY N ! ADD / ADHD! ! ! ! Y N ! Cancer! ! ! ! Y N ! HemophiliaY N ! Allergies to any Drugs! ! ! Y N ! Congenital Heart Defect!! Y N HepatitisY N ! Allergic to Latex / Metals! ! Y N ! Convulsions/Epilepsy! ! Y N HIV+ / AIDSY N ! Allergic to Plastics! ! ! Y N ! Diabetes! ! ! Y N ! Kidney/Liver ProblemsY N ! Any Hospital Stays! ! ! Y N ! Fluoride Treatments! ! Y N ! LupusY N ! Any Operations !! ! ! Y N Handicaps / Disabilities !! Y N Rheumatic/Scarlet FeverY N ! ArtiÞcial bones/Joints/valves! ! Y N Hearing Impairment! ! Y N Tuberculosis (TB)
Please discuss any medical problems that your child has had: ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !
Our ofÞce is HIPAA Compliant and is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.
I understand that the information that I have given is correct to the best of my knowledge, that it will be held in the strictest of conÞdence and it is my responsibility to inform this ofÞce of any changes in my childʼs medical status. I authorize the dental staff to perform the necessary dental services my child may need.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
The Parent or Guardian who accompanies the child is responsible for payment. Payment is due at the time service is rendered. As a courtesy we will Þle your insurance for you; any co-payment or required deductible is due at the time service is rendered. We accept assignment of insurance beneÞts and all payments made by your insurance carrier will be paid directly to our practice. In the event insurance does not pay for the services rendered, the responsible party will be billed for services in their entirety.
Signature of parent or guardian! ! ! ! ! ! ! Date: ! ! !
Medications:
Y N Autistic Y N Downs Syndrome Y N Family History of TBY N Developmentally DelayedY N Sensory Disorder (To What?)__________
Tongue Thrust
- Chronic or Acute
If “Yes”, What Type of Reaction?
Y N Autism
Privacy Consent
Your protected health information, (i.e., individually identifiable information such as names, dates, phone/fax numbers, email addresses, home addresses, social security numbers and demographic data), may be used in connection with your treatment, payment of your account or health care operations, (i.e., performance reviews, certification, accreditation and licensure).
You have the right to review our notice of privacy policy prior to signing the consent. You have the right to request restrictions on the use of your protected health information.
You may revoke this consent at any time in writing. However, such revocation will not be retro-actively effective and will only apply to actions taken after such time the consent is revoked.
Thank you for your cooperation. Please let us know if you have any questions.
I, the undersigned, do herby attest that I have afforded the opportunity to review the Clayton Kids Dentistry notice of privacy policy.
Signature of Patient/Parent (if minor):__________________________________________________
Print Name of Patient/Parent:_________________________________________________________
This form may be used to allow an adult other than a parent to serve as a proxy decision maker for routine dental care and services at Clayton Kids Dentistry.
For some families, it may be convenient to have prior authorization in place that allows routine dental care to be delivered to minors under the care of a proxy decision maker if a parent or legal guardian cannot be present to provide consent. If you would like to appoint a proxy decision maker, please review and complete the following form authorizing dental treatment or services for the care of a minor child.
AUTHORIZATION
I hereby appoint________________________________ ______________________________ NAME RELATIONSHIP as a proxy decision maker to consent to and authorize dental care for my child(ren) listed below.
This proxy extends to care deemed necessary by the dentist(s) to treat the conditions present. This consent includes, but is not limited to, routine preventive and restorative procedures. I understand that treatment recommended and rendered is based on what the dentist(s) believe is in the best interest of the patient. This treatment is NOT based on insurance coverage, and I understand that failure of an insurer to pay for a procedure does not relieve me the financial obligation for this treatment. (more than one child may be listed)
I hereby indemnify and hold harmless Clayton Kids Dentistry from any and all liability for acting in reliance on this authorization. The individual appointment as proxy is permitted to make decisions or consent to the care in my absence. I agree to accept financial responsibility for all care delivered pursuant to this authorization.
Signature of Parent or Legal Guardian Date Phone Number
Shraddha P. Kolappa DDS, PA
Financial Agreement I understand that my insurance policy is a contract between myself and the insurance company, and Clayton Kids Dentistry is not a party to that contract. I am responsible for unpaid balances and non-covered services, which may result in additional fees. I am responsible for informing the office of all changes to my information and insurance prior to my appointments. Insurance must be in force and verifiable at time of treatment, and if I do not have insurance, I agree to pay in full at the time of the appointment. Balances over 30 days may be subject to 2% late payment fee per month. I hereby assign all insurance benefits for services rendered, otherwise payable to me, directly to Clayton Kids Dentistry from Medicaid or my private insurance. I authorize Clayton Kids Dentistry to release medical information to my insurance company, its agents or any third party for use in determining my benefits. If my account enters a delinquent status, I agree to pay all costs of collections including attorney fees and court fees, if applicable. If my account enters court collection status, I accept that I will no longer be a patient of record. I understand that the fee for a returned check is $35. Clayton Kids Dentistry will maintain patient records for a minimum of seven (7) years following the latest date of service, barring any exceptions where required extended retention may be required. YOUR SIGNATURE BELOW CERTIFIES YOU HAVE READ< UNDERSTAND AND AGREE TO THE FINANCIAL AND OFFICE POLICY PROVISIONS STATED ABOVE. _______________________________ ________________________________ _____________ Print Name Sign Name Date
